Healthcare Provider Details

I. General information

NPI: 1679147938
Provider Name (Legal Business Name): CAMERON ANTTWAN BIRMINGHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2021
Last Update Date: 05/19/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 S BROOKSTONE VILLAGE DR
INDEPENDENCE MO
64057
US

IV. Provider business mailing address

1825 S BROOKSTONE VILLAGE DR APT 203
INDEPENDENCE MO
64057
US

V. Phone/Fax

Practice location:
  • Phone: 816-216-0143
  • Fax:
Mailing address:
  • Phone: 816-216-0143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101200000X
TaxonomyDrama Therapist
License NumberA176245003
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberA176245003
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: